Co-infection with malaria and HIV in injecting drug users in Brazil: a newchallenge to public health?

Aims. To describe AIDS and malaria geography in Brazil, highlighting the ro le of injecting drug users (IDUs) in malaria outbreaks occurring in malaria -free regions, and the potential clinical and public health implications of malaria/HIV co-infection. Design. Review of the available literature and o riginal analyses using geoprocessing and spatial analysis techniques. Findi ngs. Both HIV/AIDS and malaria distribution are currently undergoing profou nd changes in Brazil, with mutual expansion to intersecting geographical re gions and social networks. Very recent reports describe the first clinical case of AIDS in a remote Amazonian ethnic group, as well as malaria cases i n Rio de Janeiro state (hitherto a malaria-free area for 20 years); in addi tion, two outbreaks of both infections occurred at the beginning of the 199 0s in the most industrialized Brazilian state (Sao Paulo), due to the shari ng of needles and syringes by drug users. Spatial data point to: (a) the ex pansion of HIV/AIDS towards malarigenic areas located in the centre-west an d north of Brazil, along the main cocaine trafficking routes, with IDU netw orks apparently playing a core role; and (b) the possibility of new outbrea ks of secondary malaria in urban settings where HIV/AIDS is still expanding , through the sharing of needles and syringes. Conclusions. New outbreaks o f cases of HIV and malaria are likely to occur among Brazilian IDUs, and mi ght conceivably contribute to the development of treatment-resistant strain s of malaria in this population. Health professionals should be alert to th is possibility, which could also eventually occur in IDU networks in develo ped countries.